Emergency Medical Technician Program Description The Emergency Medical Technician program provides instruction in delivering proper emergency care to the sick and injured in a pre-hospital setting. The over all goals are to save lives, reduce complications, and combine effective interpersonal communication with medical knowledge and skills for every patient. The course follows the DOT EMT curriculum with the addition of Washington State objectives as required by the Washington State Department of Health, Division of Emergency Medical and Trauma Services. Upon completion of this course, the student who is affiliated with an EMS agency is eligible to take the state EMT certification exam. Students completing this course may also participate in the National Registry of Emergency Medical Technicians (NREMT) EMT examination. Persons Eligible for EMT Training Because of the intensity of the program and the desire to keep instructor-to-student ratio low, the class number will be limited. The following priorities will be used: 1. Ambulance Personnel (Volunteer and Paid). 2. Fire Personnel who respond to accidents. 3. Law Enforcement. 4. Ski Patrol, Search and Rescue, Emergency Response Teams. 5. Those not included in above agencies. 6. It is recommended that full-time students take no more than 15 credit hours during this quarter. Prerequisites ACCUPLACER test results copy indicating Reading 088 or higher, or transcript with

college level coursework. 17 years old, and 18 years old is required for WA State Certification High School diploma or equivalent copy Valid Driver’s license copy and physical ability Upon acceptance, submit fee for an Americhek criminal background check verifying no

disqualifying prior to the start of the EMT program. Immunizations (required documentation must be submitted on the second Thursday

of each quarter. Students will not attend Clinical Training without completion of required immunizations).

Requirements for Completion Successful completion of the course will require: 1. Attend all classes. Students with three or more unexcused absences will be dropped. 2. Demonstrate proficiency of all skills. 3. Achieve passing score on final exam.

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Walla Walla Community College 500 Tausick Way Walla Walla, WA 99362-9267 509.522.2500 Allied Health & Safety Education 509.527.4589 509.527.4226 fax

Registration Procedure Completion of this application does not guarantee admission to any EMT course. Preliminary applications will be reviewed to assure that prerequisites for enrollment in the course have been completed. Successful applicants will be notified by mail or phone and will be given further instructions for completing official registration. All students accepted into the EMT class will provide the following one week prior to the start of the EMT program:

• Submit to a Americhek background investigation by paying a NON-refundable fee of $35 to the WWCC cashiers after you get accepted. (REQUIRED ONE WEEK BEFORE CLASSES STARTS)

• Submit a current AHA Basic Life Support for Healthcare Providers card which must remain current during the entire quarter. (REQUIRED THE FIRST DAY OF CLASSES)

Immunizations: Required documentation must be submitted second Thursday of each quarter Students will not attend Clinical Training without completion of required immunizations.

Applications Please fill out the enclosed application and return to: Allied Health and Safety Education Walla Walla Community College 500 Tausick Way Walla Walla, WA 99362 Applications will be accepted until August 26, 2019. Applicants will be notified by September 3, 2019. For additional information, call 527-4589 Class Information Credits: 10 Course Number: HO 130 Classes Begin: September 23, 2019 Classes End: December 13, 2019 Time: 6:00 p.m. - 9:00 p.m. Place: Walla Walla Community College Room: 1836 Health Science Building

Days: M-TH, Weekends to be arranged for labs/clinicals Tuition and Fees Approximately: $1,363.65 (WA Residents). $1,699.75 (Out of state) Textbooks (estimated) $ 208.00 Background check fee: $ 35 Immunizations (estimated) $400

Tuition and fees are subject to change

FOR INFORMATION ONLY Accommodations for Students with Disabilities Walla Walla Community College complies with Section 504 of the Rehabilitation Act and the Americans with Disabilities Act (ADA) of 1990 as amended in 2008. Sherry Hartford, Vice President of Human Resources, (509)527-4382, serves as the Section 504 Officer. Information regarding student accommodations may be obtained by contacting Bobbie Sue Arias, Ph.D., Coordinator of Disability Support Services, Walla Walla Community College, 500 Tausick Way, Walla Walla, WA 99362. Walla Walla campus: (509) 527-4262, bobbiesue.arias@wwcc.edu; or Clarkston campus: Heather Markwalter, M.S. Counseling., 509.758.1721, heather.markwalter@wwcc.edu. Equal Opportunity Statement Walla Walla Community College District No. 20 (WWCC) is committed to provide equal opportunity and nondiscrimination for all educational and employment applicants as well as for its students and employed staff, without regard to race, color, creed, national origin, sex, sexual orientation, including gender expression/identity, genetic information, marital status, age (over 40), the presence of any sensory, mental, or physical disability, the use of trained guide dog or service animal by a person with a disability, or status as a Vietnam and/or disabled veteran, National Guard member or reservist in accordance with the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, the Federal Rehabilitation of 1973, the Americans with Disabilities Act of 1990 and any other applicable Federal and Washington State laws against discrimination. Sherry Hartford, Vice President of Human Resources (509)527-4382, has Affirmative Action/Equal Opportunity, Title IX Coordinator and Section 504 Compliance program responsibility. The College’s TDD number is (509) 527-4412. Walla Walla Community College prohibits smoking or other tobacco use, including the use of electronic cigarettes, distribution or sale of tobacco, including any smoking device, or carrying of any lighted smoking instrument within the perimeter or college property. This includes all college premises, sidewalks, parking lots, landscaped areas, sports fields; college owned, rented or leased building on campus; and college owned, rented or leased vehicles. Marijuana Use: Although the State of Washington passed a law that legalized personal use of marijuana, it is essential that students realize that Washington’s system of legalized marijuana does not preempt Federal Law. Federally, marijuana is illegal. It is listed as a Schedule 1 drug, which is defined as drugs, substances or chemicals with no currently accepted medical use and a high potential for abuse. Clinical agencies are bound by Federal Law with regards to marijuana use. As guests at our clinical agencies, we are bound by this same policy. If a student tests positive for marijuana metabolites, the student will be immediately dismissed from WWCC Allied Health Courses. Drug Testing: Although the WWCC Health Science Division does not conduct drug testing without cause, students placed at some clinical agencies will be required to submit to a mandatory urine drug-screening test before Day 1 of clinical or at any subsequent time as requested. Clery Act Notice of Jeanne Clery Act required Annual Security Report – Walla Walla Community Colleges posts an Annual Security Report online. A paper copy of the report may also be obtained free of charge by visiting the Campus Security and Environmental Health and Safety office during normal business hours. The report contains policies and procedures related to campus safety and security, three years of crime statistics and other additional safety information. (https://www.wwcc.edu/security-environmental-health-safety/clery-act-compliance/)

INTENTIONALLY LEFT IN BLANK

For official use only

Date Received

Date Acceptance

Notification

EMERGENCY MEDICAL TECHNICIAN APPLICATION Basic Life Support

(Please print legibly) Name Last First Middle Mailing Address Street City/State Zip Home Phone Cell Phone Message Phone Over 17 years of Age? Yes No Social Security # Date of Birth SID # High School graduate? Yes No Year GED? Yes No Year Email Address ________________________________________________________________ AGENCY AFFILIATON (To be completed by Agency Representative) CHIEF/SUPERVISOR or DISTRICT/AGENCY (Print) SIGNATURE MAILING ADDRESS PHONE APPLICANTS TIME WITH AGENCY Business APPLICANT’S NUMBER OF AGENCY RESPONSES THE PAST 12 MONTHS REASON(S) FOR RECOMMENDING THIS APPLICANT FOR CERTIFICATION:

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Walla Walla Community College 500 Tausick Way Walla Walla, WA 99362-9267 509.522.2500

Allied Health & Safety Education 509.527.4589 509.527.4226 fax

ENROLLMENT QUALIFICATIONS ALL INDIVIDUALS applying for admission to a Washington Emergency Medical Services Training course must meet and submit documentation of the following:

(Initial 1-4 verifying documentation has been submitted w ith application) 1. __________ Copy of Driver License verifying age of 17 or older

2. Copy of High school diploma or equivalency qualification 3. Filled out and signed Americhek Criminal background check form 4. I have the physical strength to perform the normal functions of an Emergency

Medical Technician 5. Copy of required Immunizations

CERTIFICATION You will not be eligible for state certification as an Emergency Medical Technician UNTIL you become a functioning member of one of the following Washington EMS identified agencies in the State of Washington:

• Ambulance Personnel (paid or voluntary) • Fire Personnel who respond to EMS calls (or with EMS responses) • Law Enforcement Personnel • Ski Patrol, Search & Rescue, Emergency Response Team

I HAVE READ AND UNDERSTAND ALL REQUIREMENTS THAT ARE MANDATORY FOR MY ENROLLMENT IN THE EMERGENCY MEDICAL TECHNICIAN BASIC LIFE SUPPORT TRAINING COURSE. Signature Date

DO NOT WRITE BELOW

For Allied Health Official Use Only

Documentation of the following vaccines or proof of immunity

o Two-step Tuberculosis Screening

o Varicella Vaccine (Chicken Pox)

o Measles, Mumps, Rubella (MMR)

o One-time dose of Tdap

o Hepatitis B vaccine (HBV)

o Influenza

o Americhek form submitted Results received

Revised 12/16

Background Authorization & Disclaimer

Our department policy is to first screen with Americhek Inc. and Washington State Patrol (WSP). A third background check is conducted through the Department of Social and Health Services Background Check Central Units. This is a State law requirement of every employee and every student intern in a long term care facility. It takes a minimum of three weeks for our office to receive results from the Department of Social and Health Services Background Check Central Unit. The Background Check Central Unit criminal history screen results will go directly to the clinical facility. This screening will include:

• Due process findings of abuse, neglect, abandonment, and exploitation • More specific Department of Corrections information

In the event your criminal history report results with findings that prevent you from working with vulnerable adults, you will be notified by phone and by letter. Consequently, this would prevent you from being accepted into the Medical Assisting Program. With my signature below I authorize Walla Walla Community College to:

• Release all criminal background information to the clinical facility in order to facilitate the process of my enrollment in the Emergency Medical Technician program.

• Share information between the Background Check Central Unit, Americhek Inc., WSP, the clinical facility, Walla Walla Community College Instructors and Advisors that are directly involved in my educational plan.

I understand that my ability to attend the clinical portion of this course is contingent of the results of the Americhek Inc., WSP, and Background Check Central Unit investigation. Furthermore, I understand that the Americhek Inc, WSP, and Background Check Central Unit investigation are only valid for six (6) months from the date the form is submitted.

Printed Name of Applicant

Signature of Applicant Date Signed

Walla Walla Community College 500 Tausick Way Walla Walla, WA 99362-9267 509.522.2500

Allied Health & Safety Education 509.527.4589 509.527.4226 fax

Revised 12/16

INTENTIONALLY LEFT IN BLANK

A Summary of Your Rights Under the Fair Credit Reporting Act (As Provided by the Federal Trade Commission)

Summary of Your Rights Under the Fair Credit Reporting Act The feral Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every “consumer reporting agency” (CRA). Most CRAs are credit bureaus that gather and sell information about you - - such as if you pay your bills on time or have filed bankruptcy - - to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 15 U.S.C. 1681 – 1681u, at the Federal Trade Commission’s web site (http://www.ftc.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights.

• You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you - - such as denying an application for credit, insurance, or employment - - must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report.

• You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars.

• You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items, (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless you dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise national CRAs - - to which it has provided the date - - or any error.) The CRA must give you a Written report of the investigation does not resolve the dispute; you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.

• Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address and phone number of the information source.

• You can dispute inaccurate items with the source of the information. If you tell anyone - - such as a creditor who reports to a CRA - - that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you’ve notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error.

• Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old; then years for bankruptcies.

• Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA - - usually to consider an application with a creditor, insurer, employer, landlord, or other business.

• Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not five out information about you to your employer, or prospective employer,

A Summary of Your Rights Under the Fair Credit Reporting Act (As Provided by the Federal Trade Commission)

without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission.

• You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future list. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.

• You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the FCRA, you may sue them in state or federal court.

The FCRA gives several different federal agencies authority to enforce the FCRA:

FOR QUESTIONS OR CONCERNS REGARDING: PLEASE CONTACT CRAs, creditors and others not listed below Federal Trade Commission

Consumer Response Center – FCRA Washington, DC 20580 1-877-382-4367 (Toll Free)

National banks, federal branches/agencies of foreign banks (word “National” or initials “N.A.” appear in or after bank’s name)

Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 800-613-6743

Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks)

Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 202-452-3693

Saving associations and federally chartered savings banks (word “Federal: or initials “F.S.B. appear in federal institution’s name)

Office of Thrift Supervision Consumer Programs Washington, DC 20552 800-842-6929

Federal credit unions (words “Federal Credit Union” appear in institution’s name)

National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 703-518-6360

State-chartered banks that are not members of the Federal Reserve System

Federal Deposit Insurance Corporation Division of Compliance & Consumer Affairs Washington, DC 20429 800-934-FDIC

Air, surface, or rail common carriers regulated by former Civil Aeronautics Board of Interstate Commerce Commission

Department of Transportation Office of Financial Management Washington, DC 20590 202-366-1306

Activities subject to the Packers and Stockyards Act, 1921

Department of Agriculture Office of Deputy Administrator – GIPSA Washington, DC 20250 202-720-7051

List of criminal convictions, pending charges and negative actions that automatically disqualify individuals, students from having unsupervised access to adults or minors who are receiving services in a program under Washington Administrative Code (WAC) 388-113

In addition to chapters 18.51 and 74.42 RCW, these rules are authorized by RCW 43.20A.710, 43.43.830 through 43.43.842 and 74.39A.050(8).

Section I. Disqualifying and Pending Crimes List (a) Abandonment of a child; (b) Abandonment of a dependent person; (c) Abuse or neglect of a child; (d) Arson 1; (e) Assault 1; (f) Assault 2; (g) Assault 3; (h) Assault 4/simple assault (less than three years); (i) Assault 4 domestic violence felony; (j) Assault of a child; (k) Burglary 1; (l) Child buying or selling; (m) Child molestation; (n) Coercion (less than five years); (o) Commercial sexual abuse of a minor/patronizing a juvenile prostitute; (p) Communication with a minor for immoral purposes; (q) Controlled substance homicide; (r) Criminal mistreatment; (s) Custodial assault; (t) Custodial interference; (u) Custodial sexual misconduct; (v) Dealing in depictions of minor engaged in sexual explicit conduct; (w) Domestic violence (felonies only); (x) Drive-by shooting; (y) Drug crimes, if they involve one or more of the following: (i) Manufacture of a drug;

(ii) Delivery of a drug; (iii) Possession of a drug with the intent to manufacture or deliver. (z) Endangerment with a controlled substance; (aa) Extortion; (bb) Forgery (less than five years); (cc) Homicide by abuse, watercraft, vehicular homicide (negligent homicide); (dd) Identity theft (less than five years); (ee) Incendiary devices (possess, manufacture, dispose); (ff) Incest; (gg) Indecent exposure/public indecency (felony); (hh) Indecent liberties; (ii) Kidnapping; (jj) Luring; (kk) Malicious explosion 1; (ll) Malicious explosion 2; (mm) Malicious harassment; (nn) Malicious placement of an explosive 1; (oo) Malicious placement of an explosive 2 (less than five years); (pp) Malicious placement of imitation device 1 (less than five years); (qq) Manslaughter; (rr) Murder/aggravated murder; (ss) Possess depictions minor engaged in sexual conduct; (tt) Promoting pornography; (uu) Promoting prostitution 1;

Applicants for the WWCC Allied Health programs who must satisfy background checks requirements may not work in a position that may involve unsupervised access to minors or vulnerable adults if he or she has been convicted of or has a pending charge for one of the following crimes listed in Section I: If "(less than five years)" or "(less than three years)" appears after a crime listed in Section I the individual is not automatically disqualified if the required number of years has passed since the date of the conviction. For example, if three or more years have passed since an individual was convicted of Theft in the 3rd degree that conviction would not be automatically disqualifying. If the required number of years has passed, the clinical facility must conduct an overall assessment of the person's character, competence, and suitability before allowing unsupervised access to vulnerable adults and minors.

List of criminal convictions, pending charges and negative actions that automatically disqualify individuals, students from having unsupervised access to adults or minors who are receiving services in a program under Washington Administrative Code (WAC) 388-113

In addition to chapters 18.51 and 74.42 RCW, these rules are authorized by RCW 43.20A.710, 43.43.830 through 43.43.842 and 74.39A.050(8).

(vv) Promoting suicide attempt (less than five years); (ww) Prostitution (less than three years); (xx) Rape; (yy) Rape of child; (zz) Residential burglary; (aaa) Robbery; (bbb) Selling or distributing erotic material to a minor; (ccc) Sending or bringing into the state depictions of a minor engaged in sexually explicit conduct; (ddd) Sexual exploitation of minors; (eee) Sexual misconduct with a minor; (fff) Sexually violating human remains; (ggg) Stalking (less than five years); (hhh) Theft 1; (iii) Theft from a vulnerable adult 1;

(jjj) Theft from a vulnerable adult 2 (less than ten years); (kkk) Theft 2 (less than five years); (lll) Theft 3 (less than three years); (mmm) Unlawful imprisonment; (nnn) Unlawful use of building for drug purposes (less than five years); (ooo) Use of machine gun in a felony; (ppp) Vehicular assault; (qqq) Violation of temporary restraining order or preliminary injunction involving sexual or physical abuse to a child; (rrr) Violation of a temporary or permanent vulnerable adult protection order (VAPO) that was based upon abandonment, abuse, financial exploitation, or neglect; and (sss) Voyeurism.

(2) If "(less than ten years)," "(less than five years)," or "(less than three years)" appears after a crime listed in subsection (1) of this section, the individual is not automatically disqualified if the required number of years has passed since the date of the conviction. This will result in a letter from the background check central unit indicating a character, competence, and suitability review is required before allowing unsupervised access to children or vulnerable adults. (3) When the department determines that a conviction or pending charge in federal court or in any other court, including state court is equivalent to a Washington state crime that is disqualifying under this section, the equivalent conviction or pending charge is also disqualifying.

Walla Walla Community College Allied Health Department

Revised 11/2016

Background Release Form Disclosure and Consent

In connection with my participation at clinical traning site(s) as a student of WALLA WALLA COMMUNITY COLLEGE (“the Company”), I understand that investigative inquiries may be obtained on myself by a consumer reporting agency, and that any such report will be used solely for student training-related purposes. Criminal Background Check results will be sent to selected clinical agencies upon their request. I understand that the nature and scope of this investigation will include a number of sources including, but not limited to, consumer credit, criminal convictions, motor vehicle, and other reports. These reports will include information as to my character, general reputation, personal characteristics, mode of living, and work habits. Information relating to my performance and experience, along with reasons for termination of past employment from previous employers, may also be obtained. Further, I understand that you will be requesting information from various Federal, State, County and other agencies that maintain records concerning my past activities relating to my driving, credit, criminal, civil, education, and other experiences. I understand that my consent will apply throughout my time as a student of Walla Walla Community College, unless I revoke or cancel my consent by sending a signed letter or statement to the Company at any time, stating that I revoke my consent and no longer allow the Company to obtain consumer or investigative consumer reports about me.

I understand that I am being given a copy of the “Summary of Your Rights Under the Fair Credit Reporting Act” prepared pursuant to 15 U.S.C. Section 1681-1681u. This Disclosure and Consent form, in original, faxed, photocopied or electronic form, will be valid for any reports that may be requested by the Company. I authorize without reservation any party or agency contacted by Walla Walla Community College to furnish the above-mentioned information. I hereby consent to your obtaining the above information from Washington State Patrol (WSP) and Americhek, Inc. (and/or any of their licensed agents) located at 27001 La Paz Road, Suite 300-A, Mission Viejo, CA 92691, (949)768-4434. I understand to aid in the proper identification of my file or records the following personal identifiers, as well as other information, is necessary. Print Name (Full Legal Name): (First) (Middle) (Last) Other Names Known By:

Social Security Number: - - Date of Birth: / / Current Address:

City: State: ZIP: Drivers License Number: State : By my signature, I attest that I have reviewed all information provided and that all information provide by myself is true and correct. Applicant Signature: Date:

Walla Walla Community College Allied Health Department

INFORMED CONSENT AND ACKNOWLEDGMENT OF INSURANCE AVAILABILITY

I am aware that during the practicum and/or lab experience in which I am participating under the arrangements of Walla Walla Community College, certain dangers may occur, including, but not limited to, the following:

Infectious conditions, needle punctures, allergic reactions, musculo-skeletal injuries, etc... In consideration, and as part payment for the right to participate in this practicum and/or laboratory experience and the other services of Walla Walla Community College, I have and do hereby assume all the risks involved and will hold the State of Washington, Walla Walla Community College, its employees, agents, and assigns, harmless from any and all liability actions, causes of action, debts, claims, demands of every kind and nature whatsoever, which may arise from or in connection with participation in any activities arranged for me by Walla Walla Community College. The terms thereof shall serve as a release and assumption of risk for the heirs, executors, administrators, and members of my family, including minors. By my signature on this document, I acknowledge that I have been informed and further that I understand that I should have either personal health insurance prior to enrolling in this program or that I should enroll in student health insurance. My preference is shown by my initials in the boxes next to the choices below:

� Personal Health Insurance

� Student Health Insurance

� I am refusing to enroll in any health insurance program even though I am fully aware of the risks and dangers to my personal health, which may occur during my practicum/laboratory experience arranged for me by Walla Walla Community College.

_______________ ________________________________________________ Date Signature of Student ________________________________________________ Printed Name of Student The EMT Faculty have informed me of the above.

Walla Walla Community College Health Science Education Vaccination and Tuberculosis Screening Requirements

To be completed and signed by your healthcare provider

STUDENT NAME: DATE OF BIRTH:

Nursing: TB screening must be completed AFTER June 1 each year of the program. Medical Assisting: TB screening must be completed AFTER August 10. Other programs: TB screening must be completed prior to enrollment. M. tuberculosis Screening: Persons entering Nursing Core Courses at Walla Walla Community College are required to receive baseline screening prior to entering the program, using two-step Tuberculosis Skin Testing (TST) to test for infection with M. tuberculosis. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read. A second-step TST is not required if the person has a documented TST result from any time during the previous 12 months. Interferon-Gamma Release Assays (IGRAs) can be used in place of (but not in addition to) TST in all situations in which CDC recommends TST. Persons with a baseline positive or newly positive result for M. tuberculosis infection or documentation of treatment for Latent TB Infection (LTBI) or TB disease will need one chest (x-ray) radiograph result and documentation of treatment to exclude TB disease. Persons with a positive skin test or positive IGRAs, but have a negative chest (x-ray) radiograph result will need to submit radiograph results and an annual TB Symptom Screening Form (to the right) signed by both the student and healthcare provider. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm

First-Step TST (Tuberculosis Skin Test): Date/time placed: Signature, Title, Agency: Result: ____mm. Date/time read: Sig., Title, Agency: Second-Step TST: TST tests must be administered 1-3 weeks after First-Step Date/time placed: Signature, Title, Agency: Result: ____mm. Date/time read: Sig., Title, Agency: OR

Interferon-Gamma Release Assay (IGRAS) Date of Blood Draw: Results: Signature, Title, Agency: OR

Chest X-ray (if required) Date: Results: Signature, Title, Agency: • Attach Radiology Report • If Chest X-ray is completed prior to June 1 (Nursing), August 10 (Medical Assisting), or more than

one year ago for other programs, you must complete the Annual TB Screening Form below. SECOND YEAR OF THE PROGRAM (Nursing only): One-Step TST Date/time placed: Signature, Title, Agency: Result: ____mm. Date/time read: Sig., Title, Agency: OR

Interferon-Gamma Release Assay (IGRAS) Date of Blood Draw: Results: Signature, Title, Agency: OR

ANNUAL TB SYMPTOM SCREENING FORM for those with previous Chest X-ray (see below).

ANNUAL TB SYMPTOM SCREENING FORM Required annually ONLY for those with prior Chest X-ray/positive TST/IGRAs.

Must be signed by student AND healthcare provider Date of Last Chest X-ray: SIGNS/SYMPTOMS SCREENING (Yes/No). If none of these symptoms are present, an updated chest x-ray is not necessary. Lethargy/weakness Coughing up blood Fever Unexpected weight loss Loss of appetite Chest pain Sputum-producing cough Night sweats Swollen glands

I am tuberculin positive. I have had the recommended course of treatment for Tuberculosis infection (LTBI).

I have had one negative chest x-ray since becoming tuberculin skin test positive.

If I develop any of the above symptoms, I agree to seek immediate medical attention. Student signature Date Healthcare provider signature Date

Updated Summer /2016

Walla Walla Community College Health Science Education Vaccination and Tuberculosis Screening Requirements

Page 2

STUDENT NAME: DATE OF BIRTH:

Varicella (Chicken Pox): Due to clinical agency requirements, effective Fall 2016 physician diagnosis is no longer acceptable for proof of immunity. Students must provide documentation of 2 doses of varicella vaccine given at least 28 days apart or laboratory evidence of immunity.

Vaccination Dates: 1. Signature, Title, Agency: 2. Signature, Title, Agency:

OR

Laboratory evidence of immunity: Date: Results: Signature, Title, Agency:

Measles, Mumps, Rubella (MMR): Documentation of either 2 doses of Measles and Mumps vaccines separated by 28 days or more, and at least one dose of live rubella vaccine, or laboratory evidence of measles, mumps and rubella immunity.

Vaccination Dates: 1. Signature, Title, Agency: 2. Signature, Title, Agency:

OR

Laboratory evidence of immunity: Date: Results: Signature, Title, Agency:

Tetanus-Diphtheria-Pertussis (Tdap): Must have a 1-time dose of Tdap. Must have a Td booster every 10 years.

Tdap Date: Signature, Title, Agency:

Td Booster Date (if applicable): Signature, Title, Agency:

Hepatitis B Vaccine: Series of 3 vaccines completed at 0-, 1-, and 6-month and post vaccination titer at 6-8 weeks after series completion. Minimum entry requirement: Series initiated and on schedule. Must complete series and titer prior to beginning the fourth quarter of the program.

1. Date: Signature, Title, Agency: 2. Date: Signature, Title, Agency: 3. Date: Signature, Title, Agency:

AND

Post Vaccination Titer (Mandatory for Nursing and Medical Assisting students): Date: Results: Signature, Title, Agency: I f titer is negative (anti-HBs <10mlU/ mL), please provide proof of an additional dose of HepB vaccine, followed by anti-HBs testing 1-2 months later. 1. Date: Signature, Title, Agency: Post Vaccination Titer: Date: Results: Signature, Title, Agency:

Influenza: 1 dose of the most current influenza vaccine annually.

Date: Signature, Title, Agency: SECOND YEAR OF THE PROGRAM (Nursing students only): Date: Signature, Title, Agency:

**Please be sure each section is signed and dated by your healthcare

provider.